NOSE

What are the structures you see on post nasal examination?

o Posterior end of nasal septum
o Choanae
o Posterior ends of the middle and inferior turbinates
o Nasopharyngeal end of the Eustachian tube
o Torus tubaris or tubal elevation
o Fossa of Rosenmuller

What is Cottle’s test,line and areas?

TEST: When the cheek is drawn laterally( a imaginary line drawn vertically along
the naso - labial fold and horizontal line along base of ala . the point of interaction
thumb is placed and cheek drawn laterally ) if there is improvement of airway on
the affected side it indicates abnormality of the vestibular component of nasal valve
LINE : A line drawn from the nasal spine of the frontal bone to the anterior
nasal spine of the maxilla
For any deviation anterior to the line septoplasty is done
For posterior deviations SMR is done
AREA   : Vestibular, attic, valvular, turbinal and choanal

What is Little’s  area ?

An area of arterial anastamosis between the branches of the external and internal
carotid arteries situated in the antero inferior part of the nasal septum ,Major site
of bleeding

What are the arteries taking part in the formation of Kiesselbach’s plexus?
  Anterior Ethmoidal artery      Sphenopalatine artery
  Greater palatine artery           Superior labial artery

What are the boundaries of nasal valve ?

Bounded by nasal septum , pyriform aperture and upper lateral nasal cartilage and
lies 1.3 cm from the nares at the posterior part of vestibule of nose
What is internal nasal valve ?
Erectile tissue in the inferior , middle turbinate and corresponding nasal septum
constitutes internal nasal valve
What is schneiderian membrane ?
It is another name of respiratory mucosa of nose
What is woodruffs plexus ?
Woodruffs plexus is a venous plexus on the posterior end of inferior turbinate
Why ammonia is not used to test olfaction ?
Ammonia is not used to test sense of smell as it stimulates fibres of trigeminal
nerve
What is epistaxis digitorum ?
Epistaxis digitorum bleeding from the nose due to nose pricking
What are the causes of saddle nose ?
Saddle nose may result from injury , septal absecess, syphilis , or nasal surgery
Which part of the septum is involved in tuberculosis and syphilis ?
Tuberculosis causes perforation of cartilaginous septum
Syphilis leads to perforation of bony septum
What part of nose is involved in leprosy ?
Leprosy involves anterior part of nasal septum and inferior turbinate
What are the complications of SMR operation ?
 Haemorrhage
 Septal haematoma
 Septal abscess
 Synechiae formation
 Flapping septum
 Columellar retraction
 Saddle nose deformity
What is empty nose syndrome ?
It is an iatrogenic condition caused by over enthusiastic removal of nasal
turbinates during nasal surgery
What are the causes of nasal discharge ?
Unilateral – antrochonal polyp , csf rhinnorhea , unilateral sinusitis
Bilateral – allergic rhinitis , bilateral sinusitis , atrophic rhinitis
What are the types of nasal discharge ?
Serous – acute rhinitis
Watery – CSF rhinnorhea
Mucoid – allergic rhinitis
Purulent – infected polyps , septal abscess , foreign bodies in nose
Blood tinged – rhinosporidiosis , sarcoidosis , myasis , malignancy
What are the causes of nasal obstruction ?
Unilateral – rhinolith , unilateral anterior deviated nasal septum , antrochonal
polyp , unilateral hypertrophy of turbinates ( commonest is inferior turbinate ),
synechiae , rhinosporidiosis , nasopharyngeal tumours
Bilateral – bilateral chaonal atresia , ethmoidal polyp , adenoid hypertrophy ,
deviated nasal septum (S shaped ), rhinosporidiosis . septal abscess , sinusitis
What is olfactory area?
Situated in the roof of the nasal cavity between the superior turbinate and
corresponding area of The nasal septum
What is paradoxical nasal obstruction?
A patient with a deviated nasal septum to one side complains of nasal obstruction
on the opposite side due to the compensatory hypertrophy of the inferior turbinate
on the opposite side
What is compensatory hypertrophy?
Hypertrophy of the inferior turbinate on the concave side of septal deviation to take
over the Humidification and warming
How clasiify deviated nasal septum ?
Deformity of nasal septum may be classified into:
Spurs
Deviations – ‘C’ shaped and ‘S’ shaped
Dislocations – anterior dislocation and posterior dislocation ( cottles line -A line
drawn from the nasal spine of the frontal bone to the anterior nasal spine of the
maxilla
Anterior deviation - anterior to the line , septoplasty is done
posterior deviation – posterior to the line,SMR is done
Cottle has classified septal deviations into three types :

Simple deviations: Here there is mild deviation of nasal septum, there is no nasal
obstruction. This is the commonest condition encountered. It needs no treatment.

Obstruction: There is more severe deviation of the nasal septum, which may touch
the lateral wall of the nose, but on vasoconstriction the turbinates shrink away
from the septum. Hence surgery is not indicated even in these cases.

Impaction: There is marked angulation of the septum with a spur which lies in
contact with lateral nasal wall. The space is not increased even on vasoconstriction.
Surgery is indicated in these patients.
What are the reasons for headache in deviated nasal septum?

Deviated nasal septum can lead to obstruction of sinus ostia leading to sinusitis
and headache

Pressure on the anterior ethmoidal nerve due to impaction of septum on the middle
turbinate leading to headache

What is Sluder’s neuralgia?

Pressure on the anterior ethmoidal nerve due to impaction of septum on the middle
Turbinate

What are the constituents of nasal septum?

Quadrangular septal cartilage, perpendicular plate of the ethmoid ,  vomer with
contributions from the crest of the nasal bones, nasal spine of frontal bone,
rostrum of sphenoid, crest of palatine bones, maxillary crest and anterior nasal
spine of maxilla

What is Frog face?

Broadening of the nose. May be seen in extensive ethmoidal polyposis and JNA

What is hypertelorism?
Widening of the inter canthal distance

What are the types of septal deviation?

C shaped,S shaped,septal spur and caudal septal dislocation

What are the indications for SMR?

Posterior DNS with nasal obstruction
Deviation causing Sluder’s neuralgia
To close septal perforation

What are the indications for septoplasty?

In children
In anterior deflections of septum where S.M.R is contraindicated.
In caudal dislocations
Approach route for trans-sphenoidal surgery
What are the differences between septoplasty and SMR?
                          

S.M.R
1 Usually indicated for deflections
posterior to the vertical line
passing between the nasal
processes of the frontal and
maxillary bones.
2 Killian’s incision is used. Oblique
incision about 5mm above the
caudal border of the septal
cartilage.
3 Mucoperichondrium is elevated
on both sides
4 Obstructing cartilage and bone
are removed leaving only the
dorsal and caudal struts of
cartilage.
5 Complications include
perforation, supra tip saddling ,
retraction of the columella and
septal hematoma.
6 Revision difficult
SEPTOPLASTY
Indicated for anterior segment
deflections and dislocations
Usually Freer’s hemitransfixation
incision.
Mucoperichondrium is elevated on
one or both sides.
Septal cartilage is freed from all its
attachments and maintained in its
new position by sutures after
suitable scoring.
Complications are rare
Recurrence is possible.

What are the complications of septal surgery?

          Hemorrhage                   Septal Hematoma
          Septal abscess                Septal perforation
          Columellar retraction   Flapping of the septum   
          Saddle nose                    Tip collapse
          Synechiae formation
What are the causes for septal perforation?
o Traumatic – due to septal surgery, fracture, nose picking, cautery
o Infective – syphilis (bony), leprosy (bony and cartilaginous), TB
o Malignancy
o Chemicals – cocaine, chromic acid

What is atrophic rhinitis?

Non-specific chronic inflammatory condition of the nasal cavity characterized by
progressive atrophy of the nasal mucosa with underlying turbinates resulting in
abnormal patency with yellowish  - green crust formation and usually associated
with ozaena

What is cacosmia?
Perception of bad odour

What is merciful anosmia?

Patient with atrophic rhinitis has hyposmia or anosmia but foul odour is detected
from the patient by others due to presence of foul smelling crusts

What are the organisms present in atrophic rhinitis?

Coccobacillus, Bacillus mucosus, Coccobacilus foetidus ozenae, Klebsiella and
Diphtheroids

What are the causes of Atrophic rhinitis?

Primary – cause is not known, may be due to hormonal,hereditary, autoimmune
response of Mucosa ,   zinc, iron and Vitamin A deficiency and a variant of Reflex
Sympathetic Dystrophy syndrome
Secondary – may be due to trauma, extensive nasal surgery and inflammatory due
to Tuberculosis,syphilis
What are the conventional methods of polypectomy?
o Intranasal polypectomy (avulsion)
o Intranasal ethmoidectomy
o External ethmoidectomy
o Transantral ethmoidectomy
o FESS

What are the indications for Caldwell- Luc surgery?

Chronic maxillary sinusitis unresponsive to medical treatment and minor surgical
procedures like
            antral lavage
            Recurrent antrochoanal polyp
            Trans   antral ethmoidectomy
            Suspected antral malignancy for doing a biopsy
            Removal of foreign bodies in the antrum (most common FB is tooth)
            Blow out fractures of the orbit
            Repair of oro antral fistula
            Transantral ligation of maxillary artery in the pterygopalatine fossa
            Transantral vidian neurectomy    
           
Which is the indication as well as complication for Caldwell- Luc surgery?
Oro-antral fistula

How will you treat atrophic rhinitis medically?

MEDICAL  :  
Alkaline douche with soda bicarbonate, sodium biborate and sodium chloride in
the ratio  of  1:1:2 dissolved in 280 ml of water
Application of 25% glucose in glycerine will inhibit proteolytic organisms and keep
the mucosa moist
Oestradiol in arachis oil
Injection of placentrex – biological product which has got biogenic action
Kemicetine antiozaena solution – chlormycetin,estradiol and vitamin D2
What is the surgery you do for atrophic rhinitis?
Aim is to narrow the nasal cavity and give rest to the nasal mucosa
Young’s operation /Modified Young’s operation
Lautenslager’s operation
Transpositioning of the Stensen’s duct into the maxillary antrum to moisten the
nasal cavity

What is the characteristic nasal bleeding in JNA?

Repeated unprovoked uncontrollable profuse torrential bleeding

What is the use of carotid angiography in a case of JNA and what is

therapeutic embolisation?
Angiography is done 1 or 2 days before surgery to know the vascularity of the
tumor and to know the feeding  vessel and for intentional intravascular
embolisation using gelfoam or catgut to reduce the peroperative bleeding.It can
occasionally cause cerebral embolism.

What is Holman-Miller sign?

(Radiological finding )Anterior bowing of the posterior wall of the maxillary sinus
seen in JNA

What are the functions of the nose?

           Respiration                                Air conditioning of inspired air
           Protection of lower airway           Vocal resonance
           Olfaction

What is the nerve supply of nose?

            Anterior Ethmoidal nerve
            Branches of sphenopalatine ganglion
            Branches of infraorbital nerve

What are the clinical findings in sinusitis?

          Presence of mucopurulent or purulent discharge in the meati
          Sinus tenderness
          Post nasal drip
What are the investigations you will do for a patient with DNS and sinusitis?
           Diagnostic nasal endoscopy
           X ray para nasal sinuses – Water’s view
           CT scan of the paranasal sinuses

What will you look for in the X ray?

           Anterior group of sinuses will be visualized
           Compare the sinuses on both sides
           Look for haziness,thickening of mucosa and fluid level
           Scalloped appearance of the frontal sinus

Where will you palpate for sinus tenderness?

           Maxillary sinus – Canine fossa
           Frontal sinus   -   Floor of the frontal sinus
           Ethmoidal sinus – Just medial to the medial canthus

What is antral lavage?

It is a minor surgical procedure done through the inferior meatus and puncturing
of the lateral wall to enter the maxillary antrum
           Diagnostic - aspirate can be sent for culture and sensitivity
           Therapeutic   -  antral wash can be given for chronic sinusitis
           A Tilley-Lichtwitz trocar and cannula is used

What is Pott’s puffy tumor?

It occurs as a complication of sinusitis where there is subperiosteal abscess
outside,extradural abscess   intracranially and osteomyelitis of the frontal bone in
between.

Where do the sinuses drain?

Maxillary sinus drains in the posterior part of the infundibulum into the middle
meatus
Frontal sinus drains into the middle meatus thru the frontonasal duct
Anterior ethmoid group drains into the middle meatus
Posterior ethmoid group drains into the superior meatus
Sphenoid sinus drains into the spheno ethmoidal recess
Which perforation produces whistling sound?
Small septal perforation

What is rhinolalia clausa?

Any mass or growth occluding the nasopharyngeal space producing hyponasal
voice eg. Adenoids, antrochoanal polyp

What is rhinolalia aperta?

Abnormal nasopharyngeal space or incompatability of the soft palate which fails to
approximate the nasopharyngeal isthmus e.g., cleft palate,palatal paralysis
        
Why do you get epistaxis in DNS?
Mucosa over the deviated part of septum is exposed to the drying effects of air
currents leading to formation of crusts which when removed can cause bleeding

Why do you get anosmia in DNS?

Failure of inspired air reaching the olfactory area

What is the dangerous area of face?

It includes upper lip, nasal tip and its surrounding area. Infection in this area can
spread to cavernous sinus through anterior facial or angular veins

What is rhinolith?
Stone like calcareous deposits found inside the nasal cavity
They may also show tentacles
Chiefly made of phosphates and carbonates of calcium and magnesium
These salts have been found to be deposited around a nucleus which could be
inspissated mucous,
blood clot or a small foreign body
On probing the presence of a stony hard structure[gritty sensation]
Removal – piecemeal,Caldwell-Luc or lateral rhinotomy
 What are the functions of the paranasal sinuses?
Air conditioning of respiratory air                              Help in resonance of voice
Lightening of weight of skull bones                           Thermal insulation of orbit
Help in symmetrical growth of orbit

Which bones develop osteitis and which bones develop osteomyelitis?

 Osteitis occurs in compact or ivory bone like the floor of the frontal sinus
 Osteomyelitis occurs in the diploeic bone like the anterior wall of the frontal sinus
and the maxillary alveolus

What is oroantral fistula?

 A communication between the antrum and oral cavity
May occur following dental extraction (second premolar and first molar- upper),
Caldwell Luc surgery, maxillary carcinoma

What is inverted papilloma?

Also known as Ringertz tumour
It is so named because microscopically neoplastic epithelium grows towards the
underlying stroma Seen on the lateral wall of nose Has a tendency for recurrence
and malignant transformation

What is office headache or vacuum headache?

 Headache in frontal sinusitis shows a characteristic periodicity. It comes on
waking up in the morning, gradually increases ,reaches its peak in the midday and
then starts subsiding.

What are the regions where headache occurs in sinusitis?

 Maxillary sinus  - Infraorbital pain
 Frontal  sinus – Supraorbital pain
 Ethmoid sinus – Pain over the bridge of the nose and between the eyes
Sphenoid sinus – Occipital,vertical or retro orbital pain

What is the dangerous area of nose?

  Olfactory area because infection can spread from the nose intracranially through
the pia-arachnoid sheath of the olfactory nerve through the cribriform plate of the
ethmoid
 What is septal spur?
Sharp angulation occurring at the junction of septal cartilage with the ethmoid or
vomer

What is Rhinophyma?
 Also known as potato nose, caused by the hypertrophy of sebaceous glands

What is Sampter’s triad?

  Asthma, aspirin sensitivity along with nasal polyposis

What is Kartagener’s syndrome?

Bronchiectasis,  sinusitis,situs inversus and ciliary dyskinesia

What is Young’s syndrome?

  Nasal polyposis,bronchiectasis,sinusitis and azoospermia

Why do you get altered perception of smell in atrophic rhinitis?

  Crusts may be present in the olfactory area
  Atrophy of the mucosa
  Damage to the nerve endings

How will you differentiate a polyp from a hypertrophied turbinate?

Turbinate is sensitive to touch,firm in concictency,cannot be probed all around
Polyp is insensitive to touch,soft in consistency and can be probed all around
 VIVA POLYP

How will u differentiate between a polyp and turbinate hypertrophy ?

Nasal polyp Turbinate hypertrophy
Colour Pale Pink
Consistency Soft Firm to hard
Sensitivity to probing Insensitive Sensitive
Bleeding on probing Does not bleed Bleeds on touch
Probing Can be probed all around Cannot be probed
Mobility Mobile Immobile
Decongestant test Doesn’t shrink Shrinks on application

What is Bernoulli’s phenomenon?

When gas or liquid passes through a narrow constricted area at a high velocity,
negative pressure    develops in the vicinity so that mucosa is sucked along with
occurrence of edema.

What are the types of nasal polyp?

 Antrochoanal  polyp and Ethmoidal  polyposis
What are the causes for development of nasal polyposis?
 Allergy
 Infection
 Bernoulli’s phenomenon
 Vasomotor instability
 Non allergic rhinitis with eosinophilia
 Allergic fungal sinusitis
 Associated with Karatagener’s syndrome, cystic fibrosis and Sampter’s
triad

Why antrochoanal polyp goes posteriorly?

 Because it comes out thru’ the accessory ostium which is directed
posteriorly
 The normal anatomical contour of the nasopharynx is sloping downwards
and backwards
 The mucociliary clearance is directed posteriorly
  Due to the effect of gravity

Differences between AC polyp and ethmoidal polyposis?

ETHMOIDAL   POLYP AC  POLYP

Multiple-bilateral Single-unilateral
Affects adolescents and middle age Affects children and younger
individuals
Site of origin; ethmoidal labyrinth Maxillary antrum
Aetiology: allergy and infection Aetiology is not known allergy may
play a role
Anterior rhinoscopy-multiple polypi  in Posterior rhinoscopy-single polypus
middle meatus in choana
X ray paranasal sinuses haziness in Haziness in affected antrum
ethmoidal labyrinth and often antra
Recurrences are common Recurrences are less common
           
  DD for nasal polyp.
           Hypertrophied turbinate            JNA
           Inverted papilloma                      Rhinosporidiosis
           Encephalocoele/ meningoencephalocoele in children

How will you differentiate between an AC polyp and a mass arising from the
roof of the nasopharynx?
X-ray lateral view of the nasopharynx will show a curvilinear or crescentric air
shadow between the mass and roof of nasopharynx in an antrochoanal polyp

What are the structures you see on post nasal examination?

 Posterior end of nasal septum
 Choanae
 Posterior ends of the middle and inferior turbinates
 Nasopharyngeal end of the Eustachian tube
 Torus tubaris or tubal elevation
 Fossa of Rosenmuller
Why ethmoidal polyp is bilateral and multiple?
           Because the ethmoidal labyrinth is a single midline unit
           There are 15 -20 air cells with multiple ostia

What is Frog face?

Broadening of the nose. May be seen in extensive ethmoidal polyposis and JNA

Define polyp.
Polyp is a soft, smooth, cystic swelling of mucosa usually translucent may be
opaque or pale due to exposure to air currents or trauma
Microscopically it consists of hypertrophied edematous mucosa usually lined by
ciliated columnar epithelium,may be transitional or squamous due to exposure to
air currents, consisting of fibrillar stroma with intercellular fluid spaces with
lymphocytes, polymorphs and eosinophils

Why polyp is insensitive to touch?

Because it does not have nerve endings

Why polyp does not bleed on touch?

Because it is avascular

If a polyp bleeds what will you suspect?

Infected polyp
Metaplasia to transitional or squamous epithelium due to exposure to air currents
Underlying malignancy in an elderly patient

          
What are the conventional methods of polypectomy?
o Intranasal polypectomy (avulsion)
o Intranasal ethmoidectomy
o External ethmoidectomy
o Transantral ethmoidectomy
o FESS
 CSOM VIVA QUESTION & ANSWERS

What is otitis media?

Inflammation of part of or whole of the mucoperiosteal lining of the middle ear Cleft
What do you mean by central perforation?
Perforation in the pars tensa and is surrounded all around by the pars tensa
What is subtotal perforation?
Perforation in the pars tensa which is surrounded by the fibrous annulus
What is total perforation?
Perforation in the pars tensa in which the annulus is also lost
What is marginal perforation?
Perforation at the margin of the tympanic membrane with erosion of the fibrous
annulus and bounded on one side by bone
What is attic perforation?
Perforation in the pars flaccida or Shrapnell’s membrane
How will you divide the pars tensa into 4 quadrants?
Thru a vertical line running along the handle of malleus and a horizontal line at the
level of umbo
How is the cone of light formed?
Because of the oblique attachment(550) of the pars tensa inferiorly to the inferior
aspect of the EAC which is reflected as cone of light in the antero - inferior
quadrant
If the deafness  is 45 dB or exceeds 45 dB what is your interpretation?
Ossicular disruption
Which ossicle is more prone for necrosis and why?
Lenticular process of the long process of incus because of its precarious blood
supply
Why is the discharge profuse and mucopurulent in tubotympanic
Disease ?
Because of the presence of numerous mucus secreting glands
Why do you say tubotympanic disease is safe?
 Because ventilation is good as Eustachian tube is situated anteriorly
 Presence of pseudo-stratified ciliated columnar epithelium leading to
clearance of secretions by the mucociliary clearance
 Presence of numerous goblet cells and mucus secreting glands
 No vital structures
Why is attico antral disease unsafe?
 Ventilation is poor
 Crowding of structures
 Single layer of flattened pavement epithelium, without  cilia, so no clearance
of secretions
 Vital structures like the incudostapedial joint, horizontal semicircular canal,
horizontal part of facial nerve
 Persistent negative pressure due to mucosal fold and ossicles
Why do you get foul smelling scanty discharge in attico antral disease?
 Because of the underlying osteitis
 Single pavement epithelium with no secretory activity
What is cholesteatoma?
Cystic bag like structure containing squamous epithelium and debris resting on a
fibrous tissue stroma and has the property of eroding bone
What is coalescent mastoiditis ?                                       
 Destruction of mastoid air cells .
 Pus under pressure leads to venous stasis , local acidosis , osteoclastic
decalcification and whole of mastoid antrum is converted into sac
 Creamy discharge, fever, headache, malaise and mastoid tenderness
 Postero superior osseous meatal wall sagging is present

What is McEwen’s triangle?

 Suprameateal triangle bounded by the suprameatal crest above
 posterosuperior osseous meatal wall of external auditory canal in front
 tangential line from posterior meatal wall cutting the suprameatal crest
 Surgical landmark for mastoid antrum, mastoid antrum lies at a depth of
1.5 cms
What are the investigations you will do for a patient with CSOM?
Ear swab pus for culture and sensitivity
Pure tone audiometry
X-ray of both the mastoids
What are the uses of PTA?
 To confirm the tuning fork test findings
 To know the type of hearing loss
 To know the degree of hearing loss
 To know the level of hearing loss
Why do you take an x-ray of both the mastoids?
To compare between the two sides
What do you look for in the x-ray?
 Type of mastoid-80%cellular, 20% acellular
 Mastoid outline – low lying dura and forward lying sinus plate
 Cavity in the mastoid
What is the view?
Lateral oblique view or Law’s view or schullers view
What is the differential diagnosis for cavity in the mastoid?
 A large antral cell
 Cholesteatoma cavity
 Surgical cavity
 Eosinophilic granuloma

How will you differentiate between a cholesteatomatous cavity and a

surgically created cavity?
Cholesteatomatous cavity has a sclerosed margin, surgically created cavity is
smooth
How do you do the fistula test?
 Applying intermittent pressure on the tragus
 Application of pressure using a snuggly fitting Siegle’s pneumatic speculum
What is false negative fistula test?
Fistula sign is absent in the presence of a fistula Seen in dead labyrinth
What is Hennebert’s sign?
False positive fistula test
What is Tullio’s phenomenon?
Occasionally patients with a labyrinthine fistula (third window) will experience
momentary vertigo when exposed to loud noise 
What will you do for a dry central perforation?
Myringoplasty
What is myringoplasty?
Surgical closure of perforation in the tympanic membrane
Why is ASOM more common in children?
 Eustachian tube is shorter, horizontally placed
 Upto 6 months the child is protected by the mother’s immunity, after that
there is a state of hypogammaglobulinemia
 All exanthematous fevers like measles, chicken pox are common in children
 Other reasons like overcrowding, unhygienic, poor nutrition and spread of
infection from children in day care centres and school going children

What surgery do you do for a wet ear?

Cortical mastoidectomy
What are the signs of retracted tympanic membrane?
 Distortion of the cone of light
 Foreshortening of the handle of malleus
 Prominence of the lateral process of the malleus
 Sickling/ prominent of the anterior and posterior malleolar folds
What are the functions of the Eustachian tube?
 Ventilation and regulation of middle ear pressure
 Clearance of middle ear secretions         
 Prevent reflux of nasopharyngeal secretions
What is the locking pressure of the Eustachian tube?
90 mm Hg
What is myringotomy?
Incision of the tympanic membrane to drain effusion in the middle ear and for
ventilation of the middle ear
In which quadrant myringotomy is done in ASOM?
Curvilinear incision is made in the posteroinferior quadrant to prevent the incision
from closing and to establish adequate drainage of the ear discharge
 
What type of incision is made in SOM?
Radial incision in the antero inferior quadrant as ET is present anteriorly
What is the use of acetic acid for aural toileting?
To remove the epithelial debris and by providing an acidic medium it prevents the
growth of pseudomonas.
What is light house sign?
 Pulsatile ear discharge seen in Asom /mastoiditis when production of pus exceeds
drainage and the perforation is small
What is Luc’s abscess?
Abscess at the root of zygoma
What is Bezold’s abscess?   
 Abscess tracking along the sternocleidomastoid
What is Citelli’s abscess?
Abscess tracking along the posterior belly of digastric muscle
What is Gradenigo’s syndrome?
Persistent ear discharge,lateral rectus palsy and retro-orbital pain in acute
petrositis
What are the organisms in ASOM?
Streptococcus pneumonia, Haemophilus influenza, Moraxella catarrrhalis
What are the organisms in CSOM?
Pseudomonas, Proteus, E.coli, Staph aureus, Bacteroides
What is Greisinger’s sign?
Oedema over the posterior part of mastoid due to thrombosis of mastoid emissary
vein in Lateral sinus thrombosis
What is the type of fever in lateral sinus thrombosis?
Picket fence fever
Why do you get anaemia in lateral sinus thrombosis?
Due to hemolysis caused by beta hemolytic Streptococcus
What is flamingo pink tint of Schwartz ( Schwartz sign ) ?
Reddish hue seen on the promontory thru the tympanic membrane indicative of
active focus with increased vascularity in otosclerosis
What is Bell’s palsy?
Idiopathic, sudden lower motor neuron type of facial nerve palsy unassociated with
middle ear pathology
What are the causes for pain referred to the ear?
 Lesions in the oral cavity through trigeminal nerve
 Lesions in oropharynx through glossopharyngeal nerve
(tympanic branch jacobsons nerve )
 Lesions in larynx through vagus nerve (auricular nerve branch /Arnolds
nerve)

What are the uses of Siegle’s speculum?

 Fistula test can be elicited
 Demonstrate mobility of TM
 Suction of ear discharge

What are the indications for cortical mastoidectomy?

 Also known as simple or complete or Schwartz mastoidectomy
 Acute coalescent mastoiditis incompletely resolved ASOM with reservoir sign
 Masked mastoiditis
 CSOM TTD/ SOM refractive to treatment
 Approach to endolymphatic surgery,facial  decompression,vestibulo-cochlear
nerve  section, translabyrinthine approach for cerebellopontine angle,
cochlear implant surgery, combined approach  tympanoplasty
What is the incision used for mastoidectomy?
Post aural William Wilde’s incision made 5mm behind the post auricular sulcus
starting from above the pinna to the mastoid tip
What are the parts of the middle ear?
Meso,epi and hypo tympanum
What is middle ear cleft and middle ear cavity?
 Middle ear cleft includes the Eustachian tube, middle ear cavity, aditus ad
antrum, mastoid antrum and mastoid air cells
 Middle ear cavity is that part which lies opposite to the tympanic membrane
What are the complications of mastoidectomy?
 Injury to facial nerve – pyramidal part
 Dislocation of incus
 Injury to horizontal semicircular canal
 Injury to sigmoid sinus
  Injury to dura
What is BAD syndrome?
 Bell’s phenomenon is absent
 Anaesthesia of cornea
 Dryness of eyes
What is the incision made for mastoidectomy in infants and why?
Incision is made more horizontally as the mastoid process is not developed and the
facial nerve lies exposed near its exit
DD for blue drum?
Hemotympanum,Glue ear,Glomus tumor,  Hemangioma of middle ear
What is Carhart’s notch?
Dip in bone conduction curve at 2000 Hz seen in otosclerosis
Disappears after successful stapedectomy
What is Arnold’s nerve?
Auricular branch of vagus
What is Alderman’s nerve?
Auricular branch of vagus
What is Jacobson’s nerve?
Tympanic branch of Glossopharyngeal nerve
What is Parascusis Willisi?
An otosclerotic patient hears better in noisy surroundings as people tend to raise
voice in noisy surroundings
Why is central perforation kidney shaped?
Because the central part receives poor blood supply as compared to the handle of
malleus, periphery and the pars flaccida
How will you differentiate between a traumatic perforation and a perforation
due to CSOM?
 There will be  H/O injury in traumatic perforation
 Always confined to the pars tensa, Margins are ragged
 Bleeding points present

What is deafness?
Measurable loss of hearing
Why do you use tuning fork of 512Hz and 1024Hz for testing hearing?
 Because it lies in the human speech frequency range
What is sociable hearing?
 Any patient who has a hearing loss of upto 40 dB cannot be found as having
hearing loss

What are the features of tuberculous otitis media?

 Painless,thin non odorless ear discharge
 Multiple perforations
 Hearing loss – disproportionate hearing loss
 Facial palsy
 Labyrinthitis
 Pale granulations

What are the quality of discharge ?

 Mucoid - common in CSOM
 Mucopurulent - common in CSOM associated with mastoiditis
 Serous - Common in ASOM
 Serosanguinous - ASOM and otitis externa
 Watery - CSF otorrhoea
What is three point tenderness ?
Three point tenderness is elicited by using the index finger to apply pressure over
the well of the concha, middle finger is applied over the mastoid process, and the
thumb is used over the mastoid tip. The pressure over the well of the concha
indicates tenderness over the antral area, tenderness over the mastoid process
indicates the presence of mastoiditis, and tenderness over the tip of the mastoid
process indicate inflammation and thrombosis of mastoid emissary vein.
What is the normal appearance of a normal TM ?
The color of the ear drum is pearly white in colour
Red drum - is seen in acute otitis media, glomus jugulare
Blue drum - is seen in haemotympanum, secretory otitis media
Flamingo flush drum - is seen in otospongiosis

What is tragal tenderness and what is its significance?

Severe tenderness on pressing the tragus is known as tragal tenderness.
Tenderness on movement of pinna and tragus suggest furunculosis of EAC.
What are the causes for blood stained ear discharge in AAD?
Chronic osteitis leads to formation of granulation tissue which has friable neo-
vascular tissue that can become polypoidal and bleed on slightest of trauma. This
causes blood stained ear discharge in AAD. 
Enumerate a few conditions which can present with bloody ear discharge.
Furuncle of EAC, FB in EAC, trauma of EAC,Myringitis bullosa haemorrhagica,
traumatic perforation of TM, ASOM, CSOM AAD, Glomous tumours of the  middle
ear and malignant tumours of EAC and middle ear.
What are the causes for foul smell in the discharge in AAD?
The foul odour is due to mixed flora of bacteria consisting of Pseudomonas,
Proteus. E coli, anaerobic streptococci and bacteroids. The Chronic osteitis
provides the right environment for the growth of these bacteria.
What is ABC?
Bone conduction of patient is compared with that of the examiner assuming the
examiner has normal hearing by occluding the EAC by pressing the tragus
What are the inferences of tuning fork tests?
 In normal patients air conduction is better than bone conduction i.e., Rinne
is positive and Weber is centralized
 In conductive deafness bone conduction is better than air conduction i.e.,
Rinne is negative in the affected ear and Weber is lateralized to the worst ear
 In sensorineural deafness, the air conduction is better than bone conduction
but it is reduced,Rinne is positive and Weber is lateralized to the better
hearing ear

Which material is used for myringoplasty and why?

 Temporalis fascia
 Because : It lies in the vicinity of the surgical field
 It is available in plenty
 It resembles the TM structurally
 BMR is low so the uptake ratio is good
What are the prerequisites for myringoplasty?
 Reasonably dry ear
 Adequate cochlear reserve
 Functioning Eustachian tube
 Some amount of normal middle ear mucosa
 Allergy is to be excluded
What are the advantages of myringoplasty?
 By closing the perforation in the tympanic membrane the vibratory area of
the tympanic membrane is restored, hearing is improved
 Round window is protected thereby preventing the development of
sensorineural deafness
 Prevents infection from the exterior reaching the middle ear
 Decreases the frequency of tinnitus
 Those who require binaural hearing like telephone operators are benefitted
 Patient can perform social activities like swimming
 Those with a pre-existing SN loss can fit a hearing aid
What are the types of myringoplasty?
 On lay or overlay and Underlay technique
What are the differences between pars tensa and pars flaccida?
 Pars tensa has 3 layers – outer epithelial, middle fibrous and inner mucosal
layer
 In pars flaccida middle fibrous layer is absent
 Pars tensa is attached to the tympanic sulcus
 Pars flaccida is attached to the notch of Rivinus

What are the different types of mastoid air cells?

Zygomatic cells                   Perilabyrinthine cells      Sinodural cells
Tegmen cells                       Peritubal cells                   Periantral cells
Perisinus cells                     Tip cells
Retrofacial cells                  Petrous cells

Why do you get mixed deafness in CSOM?

In long standing cases of tympanic membrane perforation the round window is
exposed to noise and toxins, leading to hair cell damage and sensorineural hearing
loss
What do you mean by tympanoplasty?
It is an operation to eradicate disease in the middle ear and to reconstruct the
middle ear hearing mechanism
What are the types of tympanoplasty?
 Type I   -   Myringoplasty
 Type II  -  Absent long process of incus , incus remnant or homograft ossicle
is shaped and placed between head of stapes and handle of malleus
 Type III -  Malleus and incus are absent,graft is placed directly over the
stapes head, also called myringostapediopexy or columellar effect
 Type IV – Round window baffle effect,only mobile foot plate of stapes is
present
 Type V – Fenestration - opening is made in the bony lateral semicircular
canal
 Type VI- Sonoversion-round window is exposed to sound
What criterion is used for grading central perforations?
 If the size of the perforation is less than the size of one quadrant of Pars
tensa, it is small
 If it is more than one but less than or equal to two it is medium
 If more than two but with significant remnant TM in one or more quadrants,
it is large
 If it involves all four quadrants and only a rim of pars tensa is remaining all
around the perforation, it is sub total
 If whole TM including the fibrous annulus is destroyed than it is called total
perforation.

What is meant by pars flaccida?

It is the superior part of Tympanic Membrane which is above the anterior &
posterior malleolar folds extending up to the outer attic wall. It forms part of the
lateral wall of epitympanum.

Why is it called pars flaccida?

It is called pars flaccida because it lacks the middle fibrous layer of TM and
appears flaccid in comparison to Pars tensa.

What are the interpretations of Weber’s test?

 Weber is central in patients with normal hearing or in patients with bilateral

equal deafness.
 It is lateralised to the affected ear in conductive deafness and to better ear in
SNHL.

How sensitive is Rinne’s test?

Rinnes’s test is not very sensitive. There should be a difference of at least 15 dB

between AC and BC for it to be significant.

How sensitive is Weber’s test?

Weber’s test is very sensitive. Even a difference of 5 dB in BC between the two ears,
weber’s test will lateralise.

What the types of deafness?

Deafness is of three types. Conductive deafness, Sensorineural deafness and mixed

deafness

Can you determine the degree of deafness by performing tuning fork tests?

Yes.

By performing Rinne’s test using 256, 512 and 1024 Hz tuning forks, one can
determine the degree of deafness.

If 256 is negative but 512 and 1024 are positive, this suggests mild conductive
deafness. If 256 and 512 are negative but 1024 is positive this suggests moderate
conductive hearing loss. If all three tuning forks show a negative Rinne, it suggests
severe conductive hearing loss. However this interpretation is valid only for
conductive deafness and not for mixed hearing loss and SNHL.
What is fistula test? How do you perform fistula test?
Fistula test is performed to detect any abnormal communication between middle
ear and inner ear. This is performed by intermittent increase in the pressure in the
EAC by repeated compression of tragus or by using a Seigle’s pneumatic speculum
and observing the patient for development of vertigo or induced nystagmus towards
the test ear.

What are the interpretations of Fistula test?

Fistula test is interpreted as Positive when on performing the test the patient
develops nystagmus with fast component towards the test ear during application of
pressure.  (Pressure should be applied and kept there for upto 30 secs to see for
nystagmus).

 When no nystagmus occurs then it is a negative fistula test.

 When the pressure is withdrawn, fast component in a positive test develops
to the opposite side.
 Presence of fistula test denotes a dehiscent sem circular canal, (most
commonly lateral).
 False positive is present in congenital syphilis (excessive mobility of stapes
footplate).
 False negative is present in dead labyrinth.

Rinnes test: Ideally 512 tuning fork is used. It should be struck against the
elbow or knee of the patient to vibrate. While striking care must be taken
that the strike is made at the junction of the upper 1/3 and lower 2/3 of the
fork. This is the maximum vibratory area of the tuning fork. It should not be
struck against metallic object because it can cause overtones. As soon as the
fork starts to vibrate it is placed at the mastoid process of the patient. The
patient is advised to signal when he stops hearing the sound. As soon as the
patient signals that he is unable to hear the fork anymore the vibrating fork
is transferred immediatly just close to the external auditory canal and is
held in such a way that the vibratory prongs vibrate parallel to the acoustic
axis. In patients with normal hearing he should be able to hear the fork as
soon as it is transferred to the front of the ear. This result is known as
 Positive rinne test. (Air conduction is better than bone conduction). In case
of conductive deafness the patient will not be able to hear the fork as soon
as it is transferred to the front of the ear (Bone conduction is better than air
conduction). This is known as negative Rinne. It occurs in conductive
deafness. This test is performed in both the ears.If the patient is suffering
from profound unilateral deafness then the sound will still be heard through
the opposite ear this condition leads to a false positive rinne.

What is are the interpretations of Rinne’s test?

Rinne’s test compares the air conduction (AC) and bone conduction(BC) in the
same ear. The interpretations are:

 Rinne positive- when AC is better than BC found in Normal hearing and

SNHL
 Rinne Negative- when BC is better than AC found in Conductive and Mixed
hearing loss.
 Rinne reduced positive- where AC is better than BC but with reduced BC
seen in SNHL
 Rinne equivocal- when AC and BC are equal seen in mild conductive
deafness.
 Rinne false negative-where BC is heard apparently longer in a case severe
unilateral SNHL as the sound is transmitted through the skull to the other
ear.
 Rinne infinitely positive- where the patient hears momentarily a vibrating
tuning fork by AC but does not hear by BC. This is seen in profound SNHL of
the test ear.
 Rinne infinitely negative – profound conductive deafness

Weber's test: Here again 512 Hz tuning fork is used. The vibrating fork is placed
over the forehead of the patient and he is asked to indicate on which side he is
hearing the sound. Normally when hearing level is equal in both the ears, it is
heard in the middle, in patients with conductive deafness the sound is heard in the
left ear. This is known as lateralisation of Weber test. If the patient is suffering from
sensorineural hearing loss then the sound is lateralised to the normal ear or the
better ear. Hence weber's test must always be interpreted along with the Rinne's
test. Weber's test is a sensitive test, it can pin point even a 10 dB hearing difference
between the ears.
Absolute bone conduction test: This test is performed to identify sensorinerual
hearing loss. In this test the hearing level of the patient is compared to that of the
examiner. The examiner's hearing is assumed to be normal. In this test the
vibrating fork is placed over the mastoid process of the patient after occluding the
external auditory canal. As soon as the patient indicates that he is unable to hear
the sound anymore, the fork is transferred to the mastoid process of the examiner
after occluding the external canal. In cases of normal hearing the examiner must
not be able to hear the fork, but in cases of sensori neural hearing loss the
examiner will be able to hear the sound, then the test is interpreted as ABC
reduced. It is not reduced in cases with normal hearing.

Myringoplasty is a surgical procedure performed to repair or reconstruct the

tympanic membrane with a suitabke graft material

Objectives

 To make ear dry

 To restore hearing

 To enable proper hearing aid usage

There are two available methods of performing myringoplasty:

Overlay technique
Under lay technique
Overlay technique:  This is a difficult technique to master.  Here the graft material
is inserted under the squamous (skinlayer) of the ear drum.  It is a difficult task
peeling only the skin layer away from the tympanic membrane, placing the graft
over the perforation and redraping the skin layer.
Underlay technique:  This is a simpler and commonly used technique.  Here the
graft is placed under the tympano meatal flap which has been elevated hence the
name under lay.  The major advantage of this procedure is that it is easy to perform
with a good success rate.

Indications of Myringoplasty:
Central perforation which has been dry atleast for a period of 6 weeks. CSOM TTD
without ossicular discontunity ( PTA less than 40 db hearing loss , more thanm
45db hearing loss suggestive of ossicular discontunity)

As a follow up to mastoidectomy procedure to recreate the hearing mechanism

Prerequisites for myringoplasty:

1. Central perforation which has been dry for atleast 6 weeks
2. Normal middle ear mucosa
3. Intact ossicular chain
4. Good cochlear reserve

Contraindications

 Acute URTI

 Otitis externa

 Uncontrolled systemic diseases

 Only hearing ear with severe SNHL of opposite side

Graft materials

 Auto graft – same person

 Isograft – genetically identical twin

 Homograft – another person ( same species )

 Heterograft – animals eg ; calf caecal serosa , bovine jugular vein

Advantages of autograft

 No immunologicl reaction

 Inexpensive

 No risk of HIV or other infections

Types of autografts

 Temporalis fascia

 Tragal perichondrium

 Conchal perochondrium

 Tragal/conchal cartilage

 Periosteum

 Fatty tissue from ear lobule

 Fascia lata

 Cadaveric dura

Advantages of temporalis fascia

 Location of donor site

 Easy to harvest

 Close embryological and histological

 Low bmr- requires less nutrition – high chances of graft uptake

 Required size can be harvested

 Can be used as onlay/intermediate/underlay grafting

 Can be used as more than one graft overlapping the other

 Can be used in sandwich technique as one of the graft with canal skin on
the fascia
Type of ear discharge

 Watery : CSF otorrhea

 Serosangunious : fungal infection , diffuse otitis externa

 Mucoidal : csom tubotympanic type

 Mucopurulent : csom tubotympanic type

 Purulent : csom atrtico antral type , furunculosis

Retraction of pars tensa ( sades classification )

 Grade 1 – mild retraction not touching the long process of incus

  Grade 2 – retracted drum touching the long process of incus

 Grade 3- retracted drum touching the promontory

 Grade 4 – drum plastered to the promontory

Retraction of pars flaccida

 Grade 1 – mild attic retraction

 Grade 2 – attic retraction touching body of incus

 Grade 3 – limitied outer attic wall erosion

 Grade 4 – severe outer attic wall erosion

Why 512 tuning fork if preferred for tests

512 hz tunning fork is preferred because it has longer tone decay , falls under
speech frequency , sound is quiet distinct from ambient noise

 Frequencies below 254 Hz are better felt than heard and hence are not used. 
Sensitivity for frequencies above 1024 Hz is rather poor and hence is not used.

Bing test:This is actually a modification of weber’s test.  The vibrating fork is

placed over the mastoid process and when it ceases to be heard the examiner’s
finger is used to occlude the external auditory canal.  In normal individuals the
sound will be heard again.  This is because by occluding the external auditory
canal the examiner is preventing sound from escaping via the external canal.  The
external auditory canal acts as a resonating chamber.  If the vibrating fork is not
heard again after the external canal is occluded then it is construed that the middle
ear conduction is the cause for deafness.  In patients with pronounced deafness if
the vibrating fork is heard after occlusion of external canal then deafness is
construed to be due to labyrinthine causes.

Gelle test:In this test, the air pressure in the external canal is varied using a
Siegle’s speculum.  The vibrating fork is held in contact with the mastoid process. 
In normal individuals and in those with sensorineural hearing loss, increased
pressure in the external meatus causes a decrease in the loudness of the bone
conducted sound.  In stapes fixation no alteration in the hearing threshold is
evident.

The following tests can be performed using a tuning fork:

1.      Rinne test

2.      Weber test

3.      ABC test

4.      Bing test

5.      Politzer test

6.      Bing Entotic test

7.      Stenger’s test

8.      Gelle test

9.      Chimani-Moos test

What is the bedside test for Eustachian tube function ?

Putting chloromycetin ear drops in ear , in case if tm is perforated the bitter taste is
felt in mouth

What is the significance of 3 finger test

  Index finger in cymba concha – tenderness here indicates suprameatal
tenderness

 Middle finger on the posterior border of mastoid – tenderness indicates

mastoditis

 Thumb at the tip of mastoid – tenderness indicates – lateral sinus

thrombophlebitis

Why is hearing better while the ear is discharging ?

Hearing in csom is better when the ear is discharging due to shielding effect of
sound window or discharge covering the perforation

What re the enzymes causing erosion in cholesteatoma

Collagenase , acid phosphotase , proteolytic enzymes , interluekins ,tumour

necrosing factors

What is patch test ?

This test is performed to know whether ossicular chain is intact or not . here a
piece of cigaraette foil or gel foam is placed over the perforation and the pta is
done . if there is subjective improvement of hearing , the patient can undergo
myringoplasty operation

What are the differences between tubotympanic and atticoantral type of COM

Tubotympanic Attico antral

Otorrhea : Profuse scanty
 Intermittent Continuous
Mucoid Purulent
Not blood stained Blood stained
Non foul smelling Foul smelling
Perforation Central perforation Marginal / attic perforation
Granulations Absent Present

THROAT
What is the function of the tonsils and adenoids?
Defence mechanism – production of lymphocytes and plasma cells
Guards the oropharynx by filtering the infection from spreading to the aerodigestive
tract –POLICEMAN
What are differences between tonsils and adenoids?
Adenoids                                         Tonsils

Single midline structure in the nasopharynx Paired bilateral structure in

oropharynx
Capsule is absent Capsule is present
Lined by pseudostratified ciliated columnar Lined by non keratinizing
epithelium squamous epithelium
No crypts,has longitudinal ridges and Numerous crypts are present
furrows
Drains to the Retropharyngeal lymph node Drains to the jugulo digastric or
Wood’s node

What is Waldeyer’s ring?

Collection of subepithelial lymphoid tissue
Inner ring – adenoids, tubal tonsils, palatine tonsils and lingual tonsils
Outer ring – submental, submandibular, facial, upper deep cervical and
retropharyngeal nodes
What is the difference between tonsil and lymph node?
Tonsil – subepithelial lymphoid tissue, no afferent only efferent
Lymph node has both afferent and efferent
Tonsil is partly capsulated and has crypts
Lymph node is encapsulated and has a cortical and medullary differentiation
What are the structures forming the bed of tonsil?
Loose areolar tissue
Pharyngobasilar fascia
Superior constrictor muscle
Paratonsillar vein
Buccopharyngeal membrane
Glossophayngeal nerve

What is Passavant’s ridge?

Mucosal elevation produced by the palatopharyngeus muscle at the level of the
nasopharyngeal Isthmus, prevents regurgitation of food from the oropharynx into
the nasopharynx
What are the muscles forming the anterior and posterior pillars?
Anterior pillar- palatoglossus muscle
Posterior pillar – palatopharyngeus muscle
What will happen if you damage the pillars during surgery?
Anterior pillar damage can lead to asymmetry
Posterior pillar injury can lead to velopharyngeal insufficiency
What is Adenoid facies?
Open mouth and mouth breathing        Pinched nostrils
Crowded teeth                                           High arched palate
Loss of nasolabial folds                             Rhinolalia clausa
Underslung mandible
Hypoplasia of maxilla                                Rounded shoulders
Vacant expression

What are the cardinal signs of chronic tonsillitis?

Flushing of the anterior pillars
Hypertrophied tonsils
Extrusion of cheesy material on pressure over the tonsils using two tongue
depressors ( positive squeeze test /Irwin mores sign)
Enlarged non tender jugulodigastric lymph node also known as Wood’s node
What is Irwin Moore’s sign?
Extrusion of cheesy material on pressure over the tonsils using two tongue
depressors
What are the types of Chronic Tonsillitis?
Chronic parenchymatous, chronic follicular and chronic fibrotic
What is the DD for a patch or ulcer over the tonsils?
         Apthous angina
         Monocytic angina
         Vincent’s angina
         Agranulocytic angina
         Leukemic angina
What are the investigations you do for a patient before tonsillectomy?
Blood hemoglobin                             RBC count
Total leucocyte count                       Differential count
 Bleeding time                                     Clotting time
  Platelet count                                     Blood glucose         
  Blood urea                                          Chest X ray
  Blood grouping and Rh typing        ECG
What is the blood supply of the tonsil?
 Arterial supply from
 Tonsillar branch of the Facial artery
 Branch from the ascending pharyngeal artery
 Descending palatine artery a branch from the maxillary artery
 Ascending palatine branch of facial artery
 Dorsalis linguae arteries
Venous  drainage  is thru the paratonsillar vein to the common facial vein and
pharyngeal plexus
What is Eagle’s Syndrome?
Elongated styloid process
Ossification of the stylohyoid ligament pressing on the tonsillar bed and the
glossopharyngeal nerve Can cause referred otalgia
What are the methods of tonsillectomy?
COLD METHODS
Guillotine                        Dissection and snare
Cryosurgery                    Harmonic scalpel
HOT METHODS
Coablation                      Laser
Electrocautery               Radiofrequency
What are the complications of tonsillectomy?
Haemorrhage
Aspiration pneumonia/collapse of lung
 Injury to teeth, lips, the anterior and posterior pillars

What is reactionary hemorrhage? What are the causes?

Bleeding occurring during the first 24 hours after surgery
It occurs due to slippage of ligature
Regaining of the normal blood pressure leading to opening of collapsed vessels
leading to bleeding
Dislodgement of clot
Clot sitting on the vessel and preventing it from contracting
What is secondary hemorrhage? What are the causes?
 Bleeding occurring within 5-10 days
 Due to infection
What is the important contraindication for adenoidectomy?
Presence of cleft palate even submucous cleft as it can lead to rhinolalia aperta
(velopharyngeal isufficiency)
What is quinsy?
Cellulitis and abscess formation between the tonsillar capsule and tonsillar bed
What are the clinical features in quinsy?
Presence of severe pain, odynophagia,trismus and restricted neck movements
Tonsil is congested
Soft palate is edematous on the affected side
Uvula is pushed to the opposite side
Enlarged tender JD node
Where will you incise a peritonsillar abscess?
The most prominent site of bulge
A line is drawn from the base of the uvula horizontally to the last upper molar tooth
and a vertical line from the anterior pillar.Incision is made superolateral to the
intersection of these two lines
What is abscess or hot tonsillectomy?
 Tonsillectomy is done at the time of an acute attack of quinsy
 Advantage is tonsil is already separated from the tonsillar bed and plane of
dissection is easy
Disadvantage is it can lead to excessive hemorrhage or aspiration,dissemination of
infection leading to bacteremia and septicemia

What is cold or interval tonsillectomy?

Tonsillectomy is done 4-6 weeks after an acute attack of quinsy after incision and
drainage and adequate antibiotic treatment
Why do you get abdominal pain during acute tonsillitis?
Due to mesenteric adenitis
How will you differentiate between acute membranous tonsillitis and
diphtheritic tonsillitis?
Epidemic of diphtheria is present
Toxic complications present
The membrane not only covers the tonsil but also extends to the uvula, soft palate
It is adherent  , peeling is difficult and produces bleeding
Membranous tonsillitis is confined to the tonsils and can be removed easil

What are the differences between IDL and direct laryngoscopy?

S.No INDIRECT LARYNGOSCOPY DIRECT LARYNGOSCOPY

1 There is foreshortening in
A.P.diameter
2 True and false cords appear to be in
contact with each other
3 Inverted mirror image is seen
4 Vocal cords look flat and white with
sharp free margin
5 The movement of vocal cords is seen
better
6 The under surface of vocal cords is
not seen
7 Ventricle is not seen
8 It is an OPD procedure
What are the causes for unilateral tonsillar enlargement?
There is no foreshortening
True and false cords are separated
by ventricle
There is no inverted image (infact
direct visualization of the structures
Vocal cords are slightly rounded
and faintly pink in colour
Movement is seen only in local
anaesthesia
The under surface of vocal cords is
not seen in this procedure also, but
some idea of under surface is gained
by pressing the vocal cord of the
opposite side by the blades of
laryngoscope
Ventricle is seen by pressing the
false cords
It is done in operation theatre.
Intratonsillar causes – tonsillolith,tonsillar cyst,peritonsillar abscess,foreign
bodies, tumors of the tonsil
Extra tonsillar causes – carotid artery
aneurysm,parapharyngealabscess,parapharyngeal tumours,
deep  lobe of parotid gland tumors

What is the importance of retromolar trigone ?

Retromolar trigone is also known as surgeons grave yard because malignancy in

this area is difficult to treat

What is surgeons grave yard ?

Floor of mouth , tonsillolingual sulcus ,vallecula, pyriformfossa , fossa of

rossenmuller

What are the causes of white patch on tonsil ?

 Infectious mononucleosis
 Diphtheria
 Vincents angina
 Membranous tonsillitis
 Thrush
 Agranulocytosis
 Acute leukemia

When are adenoids visible ?

Adenoids are clinically seen by 4th month and radiologically after 6 months of age
What is the cause of rhinolalia clausa?

Rhinolalia (hypo nasality) may be seen in nasal polyps ,

growths,allergy,adenoids.common cold , nasopharyngeal mass

What is the cause of rhinolalia aperta ?

Rhinolalia aperta(hypernasality) is seen is paralysis of soft palate, after

adenoidectomy , cleft palate , submucous cleft palate

What is the importance of fosssa of rossen muller ?

Fossa of rossenmuller is the commonest site of origin of nasopharyngeal carcinoma

What is the indication as well as complication of adenoidectomy ?

Secretory otitis media is an indication as well as a complication of adenoidectomy

How do u classify adenoid hyperplasia ?

Grade 1 – obstruction upto 1/3rd of choana

Grade 2 – obstruction of 1/3rd to 2/3rd of choana

Grade 3 – obstruction of 2/3rd to near obstruction of choana

Grade 4 – complete obstruction of choana

How is adenoid hyperplasia classified radiologically ?

7-10 mm – mild adenoid enlargement

1-1.5 cm – moderate enlargement

>1.5 cm – marked enlargement

What is the use of using H2O2 gargles ?

It is helpful because when it comes in contact with clough , there occurs release of
nascent oxygen which helps in the contraction of blood vessels expelling small
clots,thereby causing closure of mouth of vessels thus stopping bleeding

What are the causes of unilateral enlargement of tonsil ?

Peri tonsillar abscess, tonsillolith,foreign bodies , tonsillar cyst,malignancy of

tonsil, aneurysm of carotid , paraphaaryngeal abscess

How do u grade tonsil ?

 0 – tonsil in fossa
 <25% tonsils occupy oropharynx
 2 - >25% to <50%
 3 - >50% but less than 75%
 4 - >75% to 100% ( kissing tonsil )

How do you grade tonsil ?

1 –Bilateral enlargement of tonsil , tonsil within the tonsillar fossa

2 – Bilateral enlargement of tonsil , tonsil enlarged uptil the brim ( between anterior
and tonsillar pillar )

3 – Bilateral enlargement of tonsil , tonsil enlarged outside the brim , posterior

pillar cannot be visualised

4 – Bilateral enlargement of tonsil till the midline ( kissing tonsil )

What are the indications of tonsillectomy ?

Mnemonic ( PRESS & DRY CLEAN SHIRT & SAREE OF ENT PG )

Absolute indication

 Pretonsillar abscess
 Recurrent episodes of tonsillitis
 >7 episodes in 1 year
 >5 episodes in 3 year
 >3 episodes in 2 year
 Enlargement/hypertrophy of tonsil causing sleep apnoea or painfull
swallowing
 Suspicion of malignancy
 Seizures ( febrile)

Relative indication

 Diphtheria carriers
 Chronic tonsillitis causing halitosis
 Streptococcal carriers
 Streptococcal carriers causing valvular heart disease

As a part of other surgery

 Elongated styloid process ( eagles syndrome )

 Palatopharyngoplasty
 Glossopharyngeal neurectomy
What is the most important absolute indication of tonsillectomy ?

Enlargement/hypertrophy of tonsil cauing sleep apnoea and malnourished

development of child

What are the contraindication of tonsillectomy ?

Mnemonic ( A,B,C,D,E,F,G,H)

A- age less than 3 years , acute infection , anemia

B- bleeding disorders

C- carotid artery aneurysm ( absolute contraindication ), cleft palate , cervical

spondylosis

D – diphtheria carriers

E- epideminc of polio( causes bulbar poliomyelitis)

F- failure to control systemc disorders

G – gestation

H- haemolglobin less than 10 gm%